Healthcare Provider Details

I. General information

NPI: 1396791349
Provider Name (Legal Business Name): COUNTRYSIDE HEALTH CARE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 COUNTRYSIDE BLVD N
PALM HARBOR FL
34684-4928
US

IV. Provider business mailing address

3825 COUNTRYSIDE BLVD N
PALM HARBOR FL
34684-4928
US

V. Phone/Fax

Practice location:
  • Phone: 727-784-2848
  • Fax: 727-781-1402
Mailing address:
  • Phone: 727-784-2848
  • Fax: 727-781-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF11060962
License Number StateFL

VIII. Authorized Official

Name: SANDRA A. RYCZEK
Title or Position: MANAGER
Credential:
Phone: 727-784-2848